Childhood Falls in Manitoba An Assessment of Injury Severity and Fall by jennyyingdi

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									Childhood Falls in Manitoba   An Assessment
CHIRPP Report
March 2006
                              of Injury
                              Severity and
                              Fall Events by
                              Age Group




                              By:
                              Lynne Warda, MD, FRCPC
                              Medical Director, IMPACT

                              Gemma Briggs, MA
                              Research Assistant, IMPACT




                              The injury prevention centre of
                              Children’s Hospital
                              NA335-700 McDermot Avenue
                              Winnipeg, Manitoba, R3E 0T2
                              TEL: 204-787-1873
                              FAX: 204-787-2070
Table of Contents



        INTRODUCTION ....................................................................................... 2

            Background........................................................................................... 2

            Fall Classification .................................................................................. 2

            Objectives ............................................................................................. 2

        METHODS ................................................................................................ 2

        RESULTS .................................................................................................. 3

            Epidemiology ........................................................................................ 3

            Economic Impact .................................................................................. 4

            Emergency Department (CHIRPP) Data............................................... 4

            Age & Gender ....................................................................................... 5

            Fall Circumstances ............................................................................... 6

            Proportion of Falls................................................................................. 6

            Severity ................................................................................................. 6

            Contributing Factors by Age Group ...................................................... 8

        DISCUSSION .......................................................................................... 10

            Injury Patterns and Implications for Prevention................................... 10

            Age...................................................................................................... 10

            Gender ................................................................................................ 11

            Specific Injury Mechanisms................................................................. 11

        CONCLUSIONS ...................................................................................... 15

        REFERENCES ........................................................................................ 16




                                                                                       Childhood Falls in Manitoba         1
Introduction


         BACKGROUND
         As part of an evolving provincial         play equipment the leading cause
         injury prevention strategy, Manitoba      within this category.2,3
         Health and the Regional Health            OBJECTIVES
         Authorities have identified priority
                                                   This research will involve an
         areas on which to focus prevention
                                                   investigation of fall injury in Manitoba
         efforts, based on the burden of injury
                                                   using Emergency Department data
         to Manitobans. These include: motor
                                                   collected by the Canadian Hospitals
         vehicle occupant injuries, falls,
                                                   Injury Reporting and Prevention
         suicide, and drowning. A provincial
                                                   Program (CHIRPP). The CHIRPP data for
         Falls Prevention Framework is
                                                   Manitoba includes presentations at the
         currently being developed, with a
                                                   Children’s Hospital Emergency
         focus on children and the elderly, yet
                                                   Department in Winnipeg.
         provincial data on Emergency
         Department (ED) visits for fall-related
         injury are lacking. Adult fall data are   Methods
         not well captured for ED visits in
                                                   The CHIRPP child injury surveillance
         Manitoba, however, a surveillance
                                                   system collects information on
         system exists for paediatric ED
                                                   Emergency Department visits in ten
         presentations at the Winnipeg
                                                   paediatric hospitals in Canada,
         Children’s Hospital.
                                                   including the Winnipeg Children’s
         FALL CLASSIFICATION                       Hospital. This is a voluntary system in
         Falls may be classified by their          which a child’s parents and physicians
         mechanism (type or circumstance),         are requested to complete a
         which can include falls from stairs,      standardized form providing
         buildings, ladders, play equipment,       information regarding the child’s injury.
         chairs or beds, and falls during sports   A search of the Winnipeg CHIRPP
         activities. Head injuries are             database was conducted for the most
         responsible for the majority of deaths    complete five year period. Descriptive
         due to falls. The severity and            statistics are used to describe fall injury
         outcome of a fall depends on the fall     patterns and outcomes. Winnipeg
         distance, surface characteristics (e.g.   CHIRPP data are presented along with
         resiliency, contours, obstacles), and     local data regarding deaths and
         the use of any protective devices         hospitalizations for falls in an attempt
         (e.g. helmet, wrist guards).1 For         to describe the fall injury pyramid more
         children, the most frequent type of       completely. The Winnipeg Children’s
         fall leading to significant injury and    Hospital only treats children up to 16
         requiring medical treatment is from       years of age.
         one level to another, with falls from


                                                              Childhood Falls in Manitoba   2
Results

                EPIDEMIOLOGY
                                                                   children, with transport injuries being
                Falls are the leading cause of injury
                                                                   the leading cause.5 Annually, there
                hospitalization for Manitobans and the
                                                                   are approximately 570 paediatric
                third leading cause of injury death,
                                                                   hospitalizations and 3,327 Emergency
                preceded by suicide and motor vehicle
                                                                   Department visits for child fall injury
                traffic injury.4-6 Manitoba Health data
                                                                   in Manitoba.6,8 When examining
                document that approximately one
                                                                   injuries, the injury pyramid is often
                child dies from a fall each year. Fall-
                                                                   used to illustrate how the number of
                related deaths result in an average of
                                                                   injuries increases from deaths to
                5.0 potential years of life lost per
                                                                   hospitalizations, Emergency
                fatality and an average length of
                                                                   Department (ED) visits, and finally
                hospital stay of 19.8 days.6 These
                                                                   physician or clinic visits.9 While there
                results reflect the large proportion of
                                                                   are sufficient death and
                fall injuries and deaths occurring in
                                                                   hospitalization data, Emergency
                the elderly. The Manitoba College of
                                                                   Department and physician visits
                Physicians and Surgeons Child Health
                                                                   represent missing pieces of the
                Standards Committee (1990-1999) data
                                                                   pyramid. The figures below illustrate
                also illustrate that children less than
                                                                   unintentional fall deaths (1992-1999)
                15 years of age rarely die due to fall
                                                                   and hospitalizations (1992-2001) for
                injuries.7 Falls are the second leading
                                                                   Manitoba children and youth.6
                cause of head injury in Canadian

  Figure 1 & 2. Deaths (Left) and Hospitalizations - Fall Injury




                                                                             Childhood Falls in Manitoba 3
                                           workplaces, the health system, as well
Here, the ratio of male to female child
                                           as community and social services. The
deaths is 3.5:1. These gender
                                           direct costs related to the treatment of
disparities are less pronounced for
                                           falls in Manitoba account for 41% of the
paediatric fall-related hospitalizations
                                           total unintentional injury treatment
(1.66:1).
                                           costs for the province.10 Between 1999
Fall-related injuries among children       and 2002, the total cost of fall injury
tend to be less severe with increasing     for Manitoba was $335 million per year
age, with the highest rates of             with $256 million spent on direct costs.
hospitalization and death found in         Childhood falls cost the province $31
infants 0-12 months of age.5 Injury        million with an additional $28 million
patterns also vary with age. Falls         attributed to falls among youth each
among infants and toddlers frequently      year. Here, direct costs are estimated
result in minor head injuries or           at $16 million and $13 million,
concussions, and other injuries to the     respectively.10
head and face (dental injuries,
lacerations). Children 5-14 years of age
                                           EMERGENCY DEPARTMENT (CHIRPP)
are more likely to suffer fractures and
                                           DATA
dislocations. Adolescents 15-19 years of
age more often experience sprains and      All data for children less than 20 years
other soft tissue injuries. For First      of age with the injury group description
Nations Manitobans, death due to falls     code of ‘10’ for ‘falls’ were accessed
is not among the five leading causes of    for the most complete five year time
death, yet for both First Nations and      span (1999-2003). Six records were
Non-First Nations Manitobans falls are     excluded as they were considered to
the leading cause of injury                have been miscoded as a fall (five
hospitalization. Fall hospitalization      swimming/diving, one machinery). The
rates per 100,000 are 596.9 for First      final sample size was 16,636 which
Nations Manitobans and 440.5 for Non-      equates to an average of nine visits
First Nations Manitobans, with a ratio     each day for fall injury at the Winnipeg
of 1.3:1.6                                 Children’s Hospital Emergency
                                           Department. As shown in Table 1 and
                                           Figure 3, the incidence of falls was
ECONOMIC IMPACT
                                           consistent over the study period, with
Falls have a significant economic          approximately 3,330 fall presentations
impact on the province, including costs    per year among children and youth.
to individuals and their families,



                                                     Childhood Falls in Manitoba   4
Table 1. Number and Proportion of Falls by Year (CHIRPP, 1999-2003)


     Year           Number        Proportion
     1999            3486            21%
     2000            3,261           20%
     2001            3,381           20%
     2002            3,300           20%
     2003            3,208           19%
     Total          16,636           100%




             Age & Gender
             Five age groups were used to categorize       Figure 3. Falls by Year (CHIRPP,1999-2003)
             children less than 17 years of age. Falls
                                                             4,000
             occurred more among children 1-14 years
             of age (see Table 2). The proportion of         3,000

             male children injured in a fall was
                                                             2,000
             determined after the removal of cases for
             which gender was unknown. Overall,              1,000

             59.5% of Emergency Department visits for
                                                                 0
             falls were among male children, the                      1999    2000     2001   2002       2003

             proportion of males increased for
             children 10-16 years of age.



             Table 2. Falls by Age Group

              Age Group (years)         Count            Proportion          Proportion Male
              <1                           665              4%                       56.6%
              1-4                       5015              30.1%                      59.4%
              5-9                       5008               30%                       56.3%
              10-14                     4965               30%                       61.5%
              15-16                        983             5.9%                      68.7%
                             Total      16,636             100%                      59.5%




                                                                      Childhood Falls in Manitoba    5
Fall Circumstances                          floors/materials (20%), concrete/other
Injuries occurred more often on Friday      man-made surfaces (15%), ground and
(15.1%), followed by Thursday (14.8%),      other natural surfaces (13%), unknown
however for the most part the days          surface (8%), ice/snow/frost (8%), and
were fairly evenly distributed, with        stairs/steps (6%). In 32% of cases the
Monday being the day with the least         individual was engaging in a sport at
number of fall injuries (13.8%). Unlike     the time of injury. This was most often
other injury types, falls were not found    cycling (20%), with other common
to be more common on weekend days.          sports being soccer (8%), skateboarding
For time of day, falls were more            (7%), football (7%), ice hockey (7%),
common between 4:00 p.m. and 8:00           and inline skating (6%).
p.m. (35%), 12:00 p.m. and 4:00 p.m.
                                            Proportion of Falls
(30%), and 8:00 p.m. and 12:00 a.m.
(18%). Falls occurred most often in         Falls accounted for 53.6% of all injury
September (10%), followed by May            types that occurred during 1999-2003
(9.8%), June (9.4%), and August (9%).       among children less than 20 years of
The month with the least amount of          age. This amounts to over half of all
falls was December (6%).                    injury presentations to the Children’s
                                            Hospital Emergency Department in
The breakdown event was most often
                                            Winnipeg for the time period
“fell / jumped / dropped from
                                            examined.
unspecified height” (22%), followed by
loss of control (17%), fell on same level   Severity
(16%), fell ≤1M (13%), and “tripped on”     For the falls subset, 7.27% were
(12%). Excluding unspecified locations,     admitted to hospital compared with
falls were most common in the               6.51% for all types of injury within the
garden/yard (21%), followed by the          same period. As shown in Table 3, 72%
living room (11%), stairs (10%),            were treated with further follow-up
playground (9%), and bedroom (8.5%).        recommended while 20% received
Location was more often the child’s         advice. Figure 4 illustrates the
own home (38%), with other common           distribution of the 1,209 fall injury
locations being school (20%), another       admissions by age group. From this it
person’s house/apartment (11%), other       can be inferred that children 5-14 years
road (7%), or public park (6%). The         of age experience the most severe fall
main fall mechanisms were                   injuries.




                                                       Childhood Falls in Manitoba    6
              Table 3. Fall Injury Outcomes (Disposition)

               Result                                         Count                 Proportion
               Treated, follow up required                     7380                   44.36%
               Treated, follow-up whenever necessary           4557                   27.39%
               Advice only                                     3293                   19.79%
               Admitted to hospital                            1209                    7.27%
               Short stay observation in ED                    119                     0.72%
               Left without being seen by physician              67                    0.4%

               Missing                                           7                     0.04%
               Other direct admission                            2                     0.01%
               Transferred to another hospital                   2                     0.01%

                                                 Total        16,636                   100%




Figure 4. Fall-Related Hospitalizations by Age Group




                                                         <1

                                                         1-4

                                                         5-9

                                                         10-14

                                                         15-16




                                                                       Childhood Falls in Manitoba   7
Fall injuries most often resulted in a
fracture (36%), followed by an open
wound (21%), minor head injury (11%),
sprain/strain (10%), a superficial injury
(10%), or a soft tissue injury (7%). The
seventh most common outcome was a
concussion (2%). The most common
body part injured was the head/face
(34%; head – 21%), followed by the
upper extremities (forearm / elbow /
wrist - 30%), and lower extremities
(ankle/lower leg - 10%).



Contributing Factors by Age Group

The top ten fall types by age group
were determined using the variable
that describes the primary contributing
factor (Table 4). In 28% of cases the
category was listed as ‘missing’ which
restricts our findings to only those
which reported contributing factors. As
children age the contributing factors
move from home to outdoor, as well as
from furniture to playground
equipment, and later to sports-related
falls.




                                            Childhood Falls in Manitoba   8
      Table 4. Contributing Factor by Age Group

 Rank       <1 year (74%)*         1-4 years (54%)         5-9 years (52%)       10-14 years (56%)      15-16 years (62%)

 1              Beds 94                  Beds                Bikes/bike           Child other than         Snowboarding
                                                             accessories               victim
          (baby beds/cribs 8)             329                                                                    76
                                                                 381                     403

 2          Adult other than         Sofas / couch         Child other than         Bikes / bike           Skateboarding
                 victim                                         victim              accessories
                                          254                                                                    67
                   70                                            371                     390

 3           Sofas / couch              Chairs           Monkey bars/jungle        Skateboarding             Basketball
                                                             gyms etc.
                   51                     245                                            239                     62
                                                                 321

 4          Child other than         Stairs/steps           Play structure            Football              Bikes/bike
                 victim                                                                                     accessories
                                          204                    242                     217
                   27                                                                                            61

 5                Baby             Child other than       Swings/swing sets            Soccer            Child other than
           strollers/carriages          victim                   133                                          victim
                                                                                         215
                    26
                                          152                                                                    60

 6            Stairs/steps          Play structure               Beds              Snowboarding                Soccer
                   20                     95                     122                     198                     50

 7           Baby walkers          Adult other than       Children’s games           Ice hockey               Football
                                        victim
                   17                                            104                     191                     49
                                          84

 8        Baby change tables      Grocery/shopping              Soccer               Basketball             Ice hockey
                                        carts
                   16                                             94                     175                     42
                                          81

 9           Baby/child car      Monkey bars/jungle          Inline/roller          Inline/roller           Inline/roller
                 seats               gyms etc.                  skating                skating                 skating
                   15                     72                      89                     169                     20


 10       High chairs/booster            Slides            Trees/branches            Sledding /             Stairs/steps
                 seats                                                          tobogganing / snow
                                          70                      87                                             20
                                                                                  disking / tubing
                   13
                                                                                         83
                 Tables
                   13

*Percentages in brackets specify the proportion accounted for by the top ten (with missing cases removed from the denominator)




                                                                                    Childhood Falls in Manitoba         9
Discussion

                    INJURY PATTERNS AND                        Age
                    IMPLICATIONS FOR PREVENTION
                                                               This report highlights the fact that
                    Fall injuries present a significant        fall mechanisms and circumstances
                    burden for the health care system.         are age-specific. Falls at home
                    They represent over half of all ED         decrease with age while falls at
                    presentations during the examined          educational sites, sports and
                    time period (1999-2003). Head              recreational areas, and in the road
                    trauma and musculo-skeletal injuries       environment increase with age.5 As
                    are the most common fall injury            shown in other reports (see Table 5),
                    outcomes, both of which may result         infants (0-12 months) tend to fall
                    in long periods of rehabilitation and      from furniture such as sofas, beds,
                    treatment, and future disability.          cribs, stairs, and children’s products
                                                               such as baby walkers and high chairs;
                                                               toddlers (1-4 years of age) fall from
                                                               stairs, windows, and furniture (bed,
                                                               crib, chair); older children (5-9 years
                                                               of age) fall from play equipment;
                                                               youth (10-14 years of age) fall most
                                                               frequently during sports activities.1,5


 Table 5. Rank order of factors contributing to falls by age group (Victoria, Australia, 2000)

                 <1 year                 1-4 years            5-9 years             10-14 years
    1        Conventional bed         Conventional             Bicycle                 Bicycle
                                     chair/stool/seat
    2     Pram/stroller/carriage   Table/bench/counter       Monkey bar         In-line/roller skates
    3     Table/bench/counter        Conventional bed        Trampoline               Football
    4          Change table             Stair/step              Tree                 Basketball
    5           Stair/step                Bicycle           Inline/roller           Horse riding
                                                                skates
    6           High chair          Sofa/lounge/couch           Slide                Skateboard
    7       Sofa/lounge/couch           Trampoline            Bunk bed            Motor/trail/dirt
                                                                                       bike
    8         Conventional                 Slide              Flying fox              Netball
             chair/stool/seat
    9        Bouncer/rocker              Bunk bed               Swing                Stair/step
   10          Baby walker                 Swing             Stair/step                 Tree
                                                                           Childhood Falls in Manitoba 10
Gender                                      This represents a fall hazard as well
                                            as a suffocation and choking hazard.
The Winnipeg CHIRPP findings are
                                            Children frequently fall from beds.
also consistent with national statistics
                                            Winnipeg CHIRPP data identified falls
showing that males account for 62%
                                            from beds as the leading cause of
of deaths, 77% of hospitalizations,
                                            fall-related ED presentation for young
and 56% of emergency department
                                            children (<5 years of age). Several
visits due to falls among children.5 In
                                            studies have assessed falls from beds,
Winnipeg, 60% of paediatric ED
                                            their circumstances, and outcomes.
presentations were male.
                                            One study of 85 children treated in a
Specific Injury Mechanisms                  UK Emergency Department found that
Furniture                                   85% of children fell out of bed while
                                            they were asleep.12 Here, 32% of
It is important to tailor prevention
                                            cases led to the child suffering a head
efforts to the identified age-related
                                            injury while in 29% of instances the
hazards. For infants and toddlers,
                                            child sustained a fracture. Bunk bed
nursery equipment (e.g. change
                                            fall injuries are more serious, with
tables, cribs, strollers, high chairs) is
                                            significantly more brain injuries,
commonly implicated in falls. One-
                                            fractures, multiple injuries, and
third of fatal and hospitalized fall
                                            admissions to hospital.13 It is
injuries among children less than
                                            recommended that children less than
three years of age are due to falls
                                            five years of age do not sleep in bunk
from furniture.11 Active parental
                                            beds.
supervision and the vigilant use of
available restraints (waist and crotch      Baby Walkers
straps) could reduce these risks.           In April 2004, Canada became the first
Compliance with the manufacturer’s          country worldwide to ban the sale,
instructions, such as weight and            advertisement, and importation of
developmental limits for product use,       baby walkers through an amendment
and instructions for proper use (e.g.       to the Hazardous Products Act.14 Baby
not hanging materials on stroller           walker falls often result in head and
handles) could further reduce the risk      neck injuries. In one study, 29% of
of falls and injury.                        cases involved serious injuries such as
Experts recommend against placing           skull fractures, intracranial
infants to sleep on adult beds, sofas,      hemorrhage, cervical spine fractures,
or other furniture (www.cpsc.gov).          and death.15 Children who sustain baby



                                                    Childhood Falls in Manitoba 11
                                            equipment, and may be affected by
walker injuries (76%) have typically
                                            various supervision strategies.
fallen down stairs while in the device.1
In addition to ensuring that the ban is     To provide a safe playground for
enforced, it is also recommended that       children, appropriate surfaces (i.e.
parents destroy existing walkers and        sand, pea gravel, wood chips) must
not use second-hand walkers.                be continuously maintained at a safe
                                            depth, and surfacing and equipment
                                            must remain free from hazards.2
Playgrounds
                                            Close parental supervision of
Playground falls resulting in injury        preschool-aged children on
occur most often among children 5 to        playgrounds is essential. Parents
9 years of age and are the leading          should stand at arm’s-length (or less)
cause of injuries to children in the        beside preschool children, when they
school environment.16,17 Most               are climbing, on a swing, or on an
playground falls that cause injury          elevated platform.20
result from falls to the ground
                                            Sports and Recreation
surface.18 Fractures are the most
common type of playground-related           Many prevention measures should be
injury, with 80% involving the wrist,       considered for reducing the risk and
lower arm, and elbow.17                     severity of falls in sports and
                                            recreation including: (i) selecting
A national voluntary standard for
                                            appropriate activities for the child’s
playground safety was first published
                                            skills and development; (ii) discussing
by the Canadian Standards
                                            with older children and youth the
Association (CSA) in 1990. This
                                            risks of alcohol and drug use in
comprehensive standard addresses
                                            sports; (iii) use of appropriate
potential hazards through design and
                                            clothing (e.g. reflective clothing
maintenance recommendations for
                                            when in traffic) and equipment (e.g.
equipment, grounds, and surfacing.
                                            helmets, mouth guards, wrist guards);
For falls from play equipment, the
                                            and (iv) safe environments separated
risk of injury relates to the fall height
                                            from road traffic and free from fall
and the energy absorption potential
                                            hazards.21,22
of the playground surface.2 The
Canadian Paediatric Society                 Falls or collisions during sports and
recommends the use of a maximum             recreational activities are the leading
equipment height of 1.5 meters.19           cause of injury hospitalization for
The risk of falls is also related to        Canadians less than 20 years of age.5
children’s behaviour on the                 A recent analysis of the Ontario



                                                    Childhood Falls in Manitoba 12
Trauma Registry database                   extremity. The American Academy of
documented that cycling injuries           Pediatrics recently reaffirmed its
(21%) are the main cause of sports         position on banning trampolines for
and recreation hospitalizations.23 The     use in homes, schools (routine use for
CHIRPP data included falls for other       physical education classes or
summer sports including                    recreation), and outdoor play areas.26
skateboarding, soccer, inline skating,
                                           Home and Window Safety
trampoline use, and football. Winter
sports that led to fall injury visits in   While physician counselling on home
the ED included snowboarding and ice       safety may increase parental
hockey, which are more common in           awareness of home hazards, the
children 10-16 years of age. The           impact on injury is unknown.27
CHIRPP data showed that                    Window guards are effective in
snowboarding was the leading cause         preventing falls from windows.2 Many
of fall ED presentations for children      other practices have been
15-16 years of age. The Canadian           recommended by experts to reduce
Academy of Sport Medicine’s                child falls in the home and from
Snowboarding Position Statement            windows including:2,27,29
encourages the use of helmets,                1. Use safety gates at the top
particularly for children and                    and bottom of staircases
                                                 (pressure gates at bottom of
beginners 24
                                                 stairs; installed gates at the
Trampolines injuries have become                 top of stairs)
more prevalent in recent years and            2. Supervise at arms-length in
involve falls to the trampoline itself,          the bathtub and use slip-
or onto surrounding surfaces and                 resistant surfaces or a bath
                                                 mat
equipment. Trampoline injuries can
have serious outcomes including head          3. Use available safety restraints
                                                 in nursery equipment and
and cervical spine injuries.2 A
                                                 follow the manufacturers
Manitoba study of injuries to children           instructions regarding proper
less than 16 years of age using                  use (e.g. high chairs,
backyard trampolines showed that                 strollers, change tables)
most children (65%) were injured on           4. Do not leave infants
the trampoline mat, while 30% were               unattended on beds, sofas,
                                                 and change tables
ejected from the device.25 Here,
fractures and fracture-dislocation            5. Do not place infant seats and
resulted most often (75%) with the               car seats on elevated surfaces
majority (80%) to the upper



                                                   Childhood Falls in Manitoba 13
                                       less than 10cm for second or
6. Keep large toys and bumper
                                       higher storey windows
   pads out of playpens and cribs
   so children cannot climb on      8. Keep furniture away from
   them                                windows
7. Avoid falls from windows by      9. Do not allow children to play
   using operable window guards        alone on porches, balconies or
   (that allow escape in the           fire escapes
   event of a fire) or window
   limiters to limit opening to




                                        Childhood Falls in Manitoba 14
Conclusions



       Strategies to prevent falls injuries     Appropriate dissemination of
       should be tailored to childrens’         prevention information is important
       developmental stages and the             to ensure that messages reach those
       specific mechanisms identified for       responsible for caring for children
       each age group. Data sources which       (e.g. parents, babysitters, day care
       identify circumstances of injury, such   workers). Recommendations for the
       as CHIRPP data and death review          prevention of falls injuries among
       data, are vital in the assessment of     children are applicable to parents,
       these age-specific mechanisms.           individuals and organizations in the
                                                health care sector, child care, and all
                                                levels of government.




                                                        Childhood Falls in Manitoba 15
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                                                  11. Agran PF, Anderson C, Winn D,
       1. National Safe Kids Campaign. Injury         Trent R, Walton-Hayes L, Thayer S.
          Facts: Falls. Accessed October 4th,         Rates of pediatric injuries by 3-
          2004 at www.safekids.org.                   month intervals for children 0 to 3
       2. Harborview Injury Prevention and            years of age. . Pediatrics
          Research Center. Best Practices:            2003;111(6 Pt 1):e683-92.
          Falls Washington, DC: University of     12. Macgregor DM. Injuries associated
          Washington, 1997.                           with falls from beds. Inj Prev
       3. Rivara FP, Alexander B, Johnston B,         2004;6(291-2).
          Soderberg R. Population-based study     13. Belechri M, Petridou E, Trichopoulos
          of fall injuries in children and            D. Bunk versus conventional beds: A
          adolescents resulting in                    comparative assessment of fall injury
          hospitalization or death. Pediatrics        risk. J Epidemiol Community Health
          1993;92(1):61-3.                            2002;56:413-7.
       4. Health Canada. Canadian Injury          14. Health Canada. Minister Pettigrew
          Data: Mortality 1997 and                    announces a ban on baby walkers.
          Hospitalizations 1996-1997. Accessed        News Release. April 15, 2004.
          September 15, 2004 at www.hc-
          sc.gc.ca/pphb-dgspsp/injury-bles        15. Chiavello CT, Christoph RA, Bond
                                                      GR. Infant walker-related injuries:
       5. Health Canada. For the Safety of            A prospective study of severity and
          Canadian Children and Youth: From           incidence. 1994; 93 (6): 974-6.16.
          Injury Data to Preventive Measures.
          Ottawa, ON: Health Canada, 1997.        16. Mack MG, Hudson S, Thompson D. A
                                                      descriptive analysis of children’s
       6. Manitoba Health. Injuries in                playground injuries in the United
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